Notice of Privacy Practice

Missouri Plastic & Surgery, PC


This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a surgical procedure may require that your relevant protected health information be disclosed to the health plan to obtain approval for the procedure.

Health Care Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law; Public Health issues as required by law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors, Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates; Required Uses and Disclosures and other purposes as required by law.

For any purpose other than the ones described in this notice, we may only use or share your PHI when you grant us written authorization. We must obtain your written authorization prior to using your PHI for marketing materials.

If you give us written authorization to use or share your protected health information you can change your mind and revoke your authorization at any time, as long as you do so in writing. If you revoke your authorization, we will no longer use or disclose the information, but we will not be able to take back any information that we have already shared.

Your Rights

The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. We require that requests to inspect or copy protected health information be submitted in writing.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. If you ask your physician not to share your information with your health plan we will not disclose your PHI to the health plan, if you pay the full cost for your care in advance.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

You have the right to be notified of a breach of unsecured PHI.

For more Information or to Report a Complaint. If you have questions about this Notice and would like additional information, you may contact our Privacy Officer at 573-651-4488. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer at 573-651-4488 or with the Secretary of Health and Human Services. We will not retaliate against you for filing a complaint.

We reserve the right to change or modify the information contained in this Notice at any time. If we change the Notice, we make the new terms effective for all PHI that we maintain. Any changes that we make will comply with appropriate federal, state and other laws. We will make the most recent copy of this Notice available to our patients and post it in our facility. You can also call 573-651-4488 or write the Privacy Officer at 300 S. Mt Auburn Rd, Ste 100, Cape Girardeau, MO 63703 to obtain the most recent version of this Notice.

This notice was published and becomes effective on September 16, 2013.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.

Signature below is only acknowledgment that you have received this Notice of our Privacy Practices:

____________________________________ ____________________________ ____________________
Patient or Personal Representative Signature Printed Name Date

If Personal Representative’s Signature, please describe relationship to patient. _____________________________

300 S. Mt. Auburn Road | Cape Girardeau, MO 63701 | Tel: (573) 651 4488 | Fax: (573) 651 4431
Copyright 2012 Missouri Plastic and Hand Surgery, PC